Function and frailty

Assess gait, transfers, falls, weight loss, ADLs, IADLs, caregiver strain, equipment needs, home safety, and whether the treatment plan fits the patient's functional reserve.

Cognition and delirium

Separate chronic cognitive decline from acute inattention and fluctuating mental status. Medication changes, infection, urinary retention, constipation, pain, dehydration, and sleep disruption are common reversible drivers.

Polypharmacy and deprescribing

Review indication, benefit horizon, anticholinergic burden, orthostasis risk, bleeding risk, sedatives, opioids, fall risk drugs, duplicate therapy, and whether monitoring still matches the medication risk.

Goals of care

Life expectancy, symptom burden, cognition, support system, and patient priorities should change how aggressive you are with A1c targets, BP goals, cancer screening, and preventive medications.

Falls, dizziness, and syncope

Think multifactorial: medication burden, volume status, arrhythmia, neuropathy, vestibular disease, anemia, orthostasis, and environmental risk.

Constipation, incontinence, and pressure injury risk

These often reflect function, mobility, hydration, cognition, bowel regimen quality, and caregiver capacity more than one isolated organ problem.

Pain and behavior symptoms

Under-treated pain, delirium, depression, loneliness, sensory loss, and med side effects often present as agitation or "behavior change."

Delirium

Pathophysiology: Acute brain dysfunction from infection, medications, pain, urinary retention, constipation, dehydration, hypoxia, or metabolic stress causes fluctuating attention and cognition.

Diagnosis: Acute onset, inattention, altered level of consciousness, and fluctuating course; use CAM or bedside delirium assessment and search for reversible triggers.

First-line treatment: Treat the underlying cause, reorientation, hydration, sleep/wake normalization, and sensory aids.

Second-line treatment: If dangerous agitation is present, low-dose haloperidol (Haldol) or quetiapine (Seroquel) may be used with caution and close monitoring.

Dementia / Alzheimer’s disease

Pathophysiology: Progressive neurodegeneration causes memory loss, executive dysfunction, and loss of daily function; vascular disease, Lewy body disease, and mixed pathology are common in older adults.

Diagnosis: Cognitive history, functional decline, collateral history, MoCA/MMSE-type testing, medication review, and evaluation for reversible contributors such as B12, TSH, depression, or sleep disorders.

First-line treatment: Donepezil (Aricept) or rivastigmine (Exelon) for mild to moderate disease when appropriate.

Second-line treatment: Memantine (Namenda) for moderate to severe disease, plus caregiver support, safety planning, and management of behaviors without routine antipsychotics.

Depression

Pathophysiology: Late-life depression often overlaps with sleep change, grief, chronic illness, isolation, pain, and cognitive symptoms.

Diagnosis: PHQ-9 or geriatric depression screening, suicidality review, and evaluation for medical mimics such as hypothyroidism, anemia, medication effects, or dementia.

First-line treatment: Sertraline (Zoloft) or escitalopram (Lexapro) plus psychotherapy and social support.

Second-line treatment: Mirtazapine (Remeron) when appetite/sleep are issues, or duloxetine (Cymbalta) when pain and depression overlap.

Insomnia

Pathophysiology: Sleep fragmentation in older adults is often driven by circadian change, pain, mood disorder, nocturia, sleep apnea, or medication effects.

Diagnosis: Sleep history, medication review, screen for apnea/restless legs, and assess caffeine, alcohol, and daytime napping.

First-line treatment: Sleep hygiene, CBT-I, and melatonin (Mylan/OTC) when a medication is needed.

Second-line treatment: Low-dose doxepin (Silenor) or trazodone (Desyrel) in selected patients, while avoiding benzodiazepines and Z-drugs when possible.

Falls / orthostatic hypotension

Pathophysiology: Falls in older adults are usually multifactorial, often involving sarcopenia, neuropathy, vision loss, dehydration, medications, and orthostasis.

Diagnosis: Orthostatic vitals, gait/balance testing, medication review, vision/foot exam, and evaluation for anemia, dehydration, arrhythmia, or neurologic disease.

First-line treatment: Deprescribe offenders, exercise/PT, hydration, home safety changes, and compression garments when appropriate.

Second-line treatment: Midodrine (ProAmatine) or fludrocortisone (Florinef) for persistent symptomatic orthostatic hypotension when nonpharmacologic steps are insufficient.

Frailty / sarcopenia

Pathophysiology: Age-related loss of muscle mass and physiologic reserve increases vulnerability to stress, hospitalization, falls, and disability.

Diagnosis: Weight loss, weakness, slow gait, low activity, exhaustion, grip strength, and ADL/IADL decline.

First-line treatment: Resistance exercise, protein/calorie optimization, vitamin D when deficient, and reversible cause treatment.

Second-line treatment: PT/OT, assistive devices, and home-based services; anabolic drug therapy is not routine and should be specialist-directed.

Osteoporosis / fragility fracture

Pathophysiology: Reduced bone mass and microarchitectural deterioration increase the risk of hip, vertebral, and wrist fracture after low-energy trauma.

Diagnosis: DXA scan, fragility fracture history, and risk assessment; T-score at or below -2.5 supports osteoporosis.

First-line treatment: Calcium/vitamin D repletion and alendronate (Fosamax) or risedronate (Actonel) when medication is indicated.

Second-line treatment: Zoledronic acid (Reclast) or denosumab (Prolia) for higher-risk disease or oral bisphosphonate intolerance.

Osteoarthritis and chronic pain

Pathophysiology: Joint cartilage degeneration and degenerative remodeling produce pain, stiffness, and loss of function.

Diagnosis: Clinical pattern with activity-related pain, limited morning stiffness, and x-ray if diagnosis is uncertain or severe.

First-line treatment: Exercise, weight management, topical diclofenac (Voltaren), and acetaminophen (Tylenol) when appropriate.

Second-line treatment: Duloxetine (Cymbalta), oral NSAIDs when safe, or intra-articular corticosteroid injection for select joints.

Heart failure

Pathophysiology: Impaired pump function or filling leads to congestion, dyspnea, edema, and progressive neurohormonal activation.

Diagnosis: BNP/NT-proBNP, echocardiography, volume exam, renal function, and review for precipitating ischemia, arrhythmia, infection, or nonadherence.

First-line treatment: Furosemide (Lasix) for congestion and guideline-directed therapy such as carvedilol (Coreg) when tolerated.

Second-line treatment: Sacubitril/valsartan (Entresto), empagliflozin (Jardiance), and spironolactone (Aldactone) when appropriate.

Atrial fibrillation

Pathophysiology: Disorganized atrial activity promotes stasis, tachycardia symptoms, and stroke risk.

Diagnosis: ECG, thyroid/electrolyte review, echocardiography, and CHA2DS2-VASc/HAS-BLED risk balancing.

First-line treatment: Rate control with metoprolol (Lopressor/Toprol XL) or diltiazem (Cardizem/CD) if blood pressure allows.

Second-line treatment: Apixaban (Eliquis) for anticoagulation when indicated, and amiodarone (Pacerone/Cordarone) or cardioversion for rhythm strategy when selected.

Chronic kidney disease

Pathophysiology: Progressive nephron loss causes reduced GFR, albuminuria, electrolyte issues, anemia, and cardiovascular risk.

Diagnosis: eGFR trend, urine albumin-creatinine ratio, urinalysis, creatinine, potassium, bicarbonate, and renal imaging when obstruction is suspected.

First-line treatment: Lisinopril (Zestril/Prinivil) or losartan (Cozaar) for albuminuric disease.

Second-line treatment: Empagliflozin (Jardiance) or dapagliflozin (Farxiga) with nephrology referral for rapid progression or advanced CKD.

COPD

Pathophysiology: Chronic airway inflammation and fixed obstruction from smoking or exposure produce dyspnea, cough, and exacerbations.

Diagnosis: Post-bronchodilator spirometry, symptom burden, exacerbation history, and oxygenation assessment.

First-line treatment: Tiotropium (Spiriva) or albuterol/ipratropium (Combivent) and smoking cessation.

Second-line treatment: Budesonide-formoterol (Symbicort), prednisone (Deltasone), and azithromycin (Zithromax) when exacerbation infection is suspected.

Constipation / fecal impaction

Pathophysiology: Reduced motility, dehydration, immobility, medications, and poor bowel routines cause stool retention and possible impaction.

Diagnosis: Stool frequency/history, abdominal/rectal exam when appropriate, and review for obstruction red flags.

First-line treatment: Polyethylene glycol 3350 (MiraLAX) plus hydration, fiber, and scheduled toileting.

Second-line treatment: Senna (Senokot), lactulose (Enulose), or manual/disimpaction approaches for severe impaction.

Urinary incontinence

Pathophysiology: Stress, urge, overflow, functional, and medication-related incontinence are common and often multifactorial in older adults.

Diagnosis: Urinalysis, postvoid residual when needed, medication review, and assessment of mobility, cognition, and pelvic floor function.

First-line treatment: Bladder training, pelvic-floor therapy, fluid timing, and mirabegron (Myrbetriq) for overactive bladder when medication is needed.

Second-line treatment: Tolterodine (Detrol LA) or oxybutynin (Ditropan) only when benefits outweigh anticholinergic risk in older adults.

UTI

Pathophysiology: Ascending bacterial infection can present atypically in older adults, especially with functional decline, fever, or delirium.

Diagnosis: Symptomatic urinary complaint plus urinalysis and culture; avoid treating asymptomatic bacteriuria in most older adults.

First-line treatment: Nitrofurantoin (Macrobid) for uncomplicated cystitis when renal function allows, or cephalexin (Keflex) when appropriate.

Second-line treatment: TMP-SMX (Bactrim DS) or ceftriaxone (Rocephin) for more complicated infection or pyelonephritis.

Pressure injuries

Pathophysiology: Sustained pressure, shear, moisture, and malnutrition cause ischemic skin breakdown and ulceration.

Diagnosis: Skin exam, stage the wound, and assess mobility, nutrition, continence, and perfusion.

First-line treatment: Offloading, turning schedules, wound care, nutrition support, and pain control.

Second-line treatment: Treat infection if present with antibiotics such as cephalexin (Keflex) or amoxicillin-clavulanate (Augmentin) when clinically indicated, plus specialty wound referral for deep ulcers.

Type 2 diabetes in older adults

Pathophysiology: Insulin resistance and beta-cell decline drive hyperglycemia, but geriatric care must also account for hypoglycemia vulnerability and function.

Diagnosis: A1c, glucose logs, renal function, and individualized targets based on cognition, frailty, and life expectancy.

First-line treatment: Metformin (Glucophage) when tolerated and kidney function allows, plus nutrition/activity support.

Second-line treatment: Dapagliflozin (Farxiga), empagliflozin (Jardiance), semaglutide (Ozempic/Rybelsus), or basal insulin glargine (Lantus/Basaglar) when needed with caution for hypoglycemia.

Polypharmacy / deprescribing

Pathophysiology: Medication accumulation, drug-drug interactions, and anticholinergic/sedative burden can worsen falls, cognition, constipation, and adherence.

Diagnosis: Complete medication reconciliation, indication review, renal/hepatic dose check, and Beers Criteria-style risk review.

First-line treatment: Stop nonessential or duplicative medicines and reduce high-risk sedatives/anticholinergics when possible.

Second-line treatment: Structured tapering plans and safer substitutions, with pharmacist collaboration for complex regimens.

Hypothyroidism and anemia

Pathophysiology: Low thyroid hormone and low hemoglobin commonly present as fatigue, weakness, constipation, and cognitive slowing.

Diagnosis: TSH/free T4 for thyroid disease; CBC, ferritin, B12, and iron studies for anemia workup.

First-line treatment: Levothyroxine (Synthroid/Levoxyl) or iron replacement such as ferrous sulfate (Feosol/Fer-In-Sol).

Second-line treatment: Optimize absorption, review for bleeding or malabsorption, and address B12 deficiency with cyanocobalamin (Nascobal/Nasal B12 or oral forms) when indicated.

Advanced care / goals of care

Pathophysiology: Serious multimorbidity, frailty, and limited physiologic reserve change the balance between preventive care, symptom relief, and life-prolonging treatment.

Diagnosis: Functional history, prognosis discussion, caregiver assessment, and capacity/surrogate review when decisions become complex.

First-line treatment: Symptom-focused care aligned with patient goals, simplified regimens, and advance care planning.

Second-line treatment: Specialty/palliative care collaboration for recurrent hospitalizations, escalating symptom burden, or uncertain decision-making.